Computer Gaming Addiction

Gaming Disorder Prevention and Treatment Treating Fire with Fire

Kenneth Woog, BS EEE, MBA, Psy.D. Debra Woog, MA, LMFT, MPC Computer Addiction Treatment Program of Southern California computeraddictiontreatment.com Presentation: computergamingaddiction.com/treatingfirewithfire.pdf

Kenneth Woog, BS EEE, MBA, Psy.D. Computer Addiction Treatment Program of Southern California computeraddictiontreatment.com [email protected] (949) 422-4120 (c)2019 Kenneth M. Woog, Psy. D. 2 Gaming Disorder Prevention and Treatment Treating Fire with Fire

Kenneth Woog, BS EEE, MBA, Psy.D. Other affiliations: Sentinel Gaming Systems, Partner Pepperdine University GSEP, PRYDE Program Director and Clinical Supervisor

Debra Woog, MA, LMFT, MPC Computer Addiction Treatment Program of Southern California computeraddictiontreatment.com [email protected] (949) 233-9058

• Hand/eye coordination • Cognitive skills • Increased creativity • Spatial visual skills • Problem solving skills • Multitasking skills • Leadership /Teamwork • Socialization opportunities • Learning strategies • Improved mood

* Not all games or game genres offer specific benefits

• Health Problems • Vision • Repetitive stress injuries • Disordered sleep/eating • Psychological Problems • Anxiety/depression • Gaming Disorder/Addiction • Cognitive fatigue • Truancies / Academic Failure

• Reduced socialization Victoria Dunckley, MD: The Overstimulated Child: Physiology, Symptoms, and Reversal of Screen Time Impacts on Mental Health • Family / marital conflict Wednesday 8:15am

* Not all games or game genres, result in these problems

(c)2019 Kenneth M. Woog, Psy. D. 7 Agenda • What is Gaming Disorder? Definitions • History of Videogame Addiction Research and Treatment • Use, prevalence and treatment surveys • Treatment outcome studies, challenges • Development of a harm reduction treatment model • Gaming Disorder research, diagnosis and treatment methods: 2019 • Developing a Gaming Addiction Treatment Model • Proposed Models of Videogame Addiction and Dependency • Theoretical functional analysis of treatment methods • Proposed treatment protocol • Supports both treatment and evaluation of outcomes • Case Studies • Prevention and Early Intervention • Informed From Research and Clinical Experience (c)2019 Kenneth M. Woog, Psy. D. 8 Trivia Question In what decade did the first legislation appear before the house of commons in Britain proposing the regulation of a very popular videogame, available for sale today, because of concerns young people were becoming addicted?

2010- 2019 2000-2009 1990-1999 1980-1989 1970-1979

(c)2019 Kenneth M. Woog, Psy. D. 9 1981 May 20, 1981, George Foulkes, MP, introduced a bill titled "Control of Space Invaders and Other Electronic Games." “That is what is happening to our young people. They play truant, miss meals, and give up other normal activity to play "space invaders". They become crazed, with eyes glazed, oblivious to everything around them, as they play the machines. It is difficult to appreciate unless one has seen it for oneself.”

Walmart $299

IBM PC 1-2 phones per household

Space Shuttle Launch Atari 2600 Console

PS4

Xbox One

iPotty

DFC Intelligence 2019

(c)2019 Kenneth M. Woog, Psy. D. 13 Video Gaming Goes Pro • $100s of Millions Committed to League Play • Fierce Competition Between Top Gaming Companies • Streaming and television viewing income • eSports Leagues Now at High School and Colleges • College Scholarships Now Available

• 16 y/o teen wins $3 million Fortnite Championship 2019! Problem: Games played and amount of play (hours) put players at risk of addiction and other health problems

Copyright© 2013 NBC Universal All Rights Reserved, Reproduced under Fair Use (Title 17: Chapter 1 § 107) 15 Gaming Disorder (aka Videogame Addiction) “a pattern of gaming behavior (“digital-gaming” or “video-gaming”) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences”

World Health Organization (2019)

“A game in which you press buttons to control and move images on a screen.” (Oxford)

(c)2019 Kenneth M. Woog, Psy. D. 17 Video Game Definition (2019) “Behavioral interventions designed using principles of psychology applied to individuals, often in groups, through electronics means with visual images, sound and user interaction. Commonly provided in exchange for financial compensation, the application of these interventions is intended to facilitate the stimulation of the mesolimbic dopamine (reward) pathways of the brain to enhance motivation for the repeated application of the interventions.” (Woog)*

*Albeit cynical, even videogames designed as a therapeutic tool for treating physical and/or mental health conditions meet this definition

That you buy and/or pay for indirectly through purchases in the game

That are so fun that you want to play them a lot

(c)2019 Kenneth M. Woog, Psy. D. 19 Video Games 2019 • Sophisticated behavioral interventions • Designed using principles of developmental, social and behavioral psychology • High user involvement through • Powerful sensory stimulation • Social involvement through significant personal relationships • High user involvement is very valuable financially - billions of dollars at stake • New business models require as much screen time as possible • Critical that users do not get satiated and change to different games • Highly competitive industry • Parents unable to monitor and or limit the delivery of these interventions • Delivered through a variety of devices that are difficult for parents to manage: Computers, laptops, tablets, game consoles, handheld gaming devices, cell phones • Parents may often give up trying • Excess use results in serious problems for users and their families • Health problems, psychiatric and psychological problems, academic, career and social problems including serious family conflict

• 1980s - Anecdotal reports emerging • Computer Addiction? Shotton, 1989 • Surveyed 127 teen/young adult males • Looked at all computing activities • Multi-user Dungeons and Dragons “…the MUD players hours were perhaps the most disruptive of their family lives than any other group” • 1990s Self report surveys • Fisher, Griffiths - Prevalence: 6% , 20%

(c)2019 Kenneth M. Woog, Psy. D. 21 Problematic Gaming Research 2000s • Research Expanding Worldwide- 2.5-34% • 2005, 2007 Germany Grusser 15+y/o (n>7000) 9.3-11.9% • 2007 S. Korea. Lee & Han 5/6th graders (n=2584) 2.5% • 2007 Taiwan. Wan & Chiou 17-24 y/o (n=416) 34% • 2008 China. Xu & Yuan 13-18 y/o (n=623) 21.5% • 2009 Austria. Battrhyany 13-18 y/o (n=1068) 2.7% • 2009 Holland. Lemmens 12-18 y/o (721) 1.4-9.4% • 2009 US. Gentile 8-18 y/o (1178) 8.5% • Nationwide Harris Poll Online survey • Criteria similar to pathological gambling • Problems correlated to 25 hrs./week of game play • 2010 Australia. Thomas, Porter 14-54 y/o, 5-8%

• Client 1: Attempted to strangle mother with power cord when she unplugged the computer • Client 2: Had not been attending school for 3 months • Both: • Intact families, professional middle class, stay-at-home mothers • No history of mental illness or substance use disorders • No prior history of mental illness or behavior problems • No prior individual or family counseling • Both serious decline in academic performance • Both serious family conflict - child/parent, child/sibling and marital

(c)2019 Kenneth M. Woog, Psy. D. 23 My First Gaming Disordered Clients: 2002 Initial Conceptualization: “Bad Parenting” • Parents had let this get out of control • Treatment: • Individual counseling: Not helpful, clients not interested in counseling • Family/Parent counseling and behavioral contracting • Both able to work around parental controls • Cycles of removing / returning the computer created more problems • Medication: Both placed on SSRIs: ineffective • Suicidality: Both hospitalized • Reconceptualization: Addiction? • Internet / Gaming Addiction was controversial, limited research • Decided to conduct my own research on what this was and how it could be treated

Yee, 2002

• Post Card Mail Survey, postage paid 2003/2004 • 5000 MD, Psych, MFT (229 responses) across US • How many clients seen, what age groups? • Clinicians saw 3 clients/yr., avg, 0.66 (11-17) • What problematic uses seen (by age group) • How diagnosed? Successful treatment methods? • Did they know someone personally with these problems? >50%

(c)2019 Kenneth M. Woog, Psy. D. 26 Problematic Uses by Age Group Woog (2004) Age 11-17 Age 18-25 Age 26+ Games 41% 18% 13% Chat 34% 21% 19% Sexual 25% 32% 54% Online Relations 23% 28% 32% Web Surfing 11% 12% 13% Gambling 0% 4% 13% Shopping 0% 4% 10% Programming 0% 4% 3%

• Psychotherapy (CBT) - (45%) • Family / Marital Counseling (34%) • Behavior Therapy (33%) • Medication (32%) 11% respondents were psychiatrists • Abstinence (18%) • 12 step programs, on-line, gameaholics anon (18%) • Controlled Use (moderation) (17%) • Parent Counseling (15%) • Social Skills Training (12%) • Addiction Counseling (11%) • Control / Monitoring Software - (8%)

% of respondents No Yes Can be Don't Know Treated prior 12 months 28 19 33 20 Not Treated 44 15 15 26

Responded “Yes” or “Can be” a distinct disorder: Treated within past 12 months: 52% Not treated within past 12 months: 30%

Blackberry 7100t BrickBreaker Game Windows XP Gaming PC

World of Warcraft Sony PS2 Released

(c)2019 Kenneth M. Woog, Psy. D. 30 Problematic Gaming Patterns 2004 • Primarily affecting teens and young adults • Increasing game play, starts with a few hours -> 35+ hrs/week • Baby sitter, low cost entertainment • “At least he is not going out and getting into trouble” • Increasing social and team involvement and responsibility to team members - > play, > rewards (loot) • Decreasing real life social involvement • Weekend play binges - 12hrs+ / day • Play commitments often 7 days a week • Increasing effort made to manage lifestyle • Do minimum in school, sports, work, poor sleep habits, etc. • School refusal “anxiety”, “bullying”, “stomach problems” common • Increasing parent-child conflict • Violence when computer removed or shut down

Child Abuses Computer Period of escalating anger, poor school performance, sleep Parents remove Repeated issues cycles keyboard/mouse/power cord/router damage or install/use parental control software relationship Child challenged to find covert Child’s obtains hardware or solution to bypass control. defeats parental Highly reinforcing for both controls/software Child and Parent! Technology divide a parental vulnerability! “Beat the Parents Game!” Options: 1. Play BTPG for months/years 2. Parents give up 3. Remove computer from home 4. Seek professional tx (c)2019 Kenneth M. Woog, Psy. D. 33 2. Abstinence / Relapse Cycle

Period of escalating Child Abuses Computer anger, poor school performance, sleep issues. Deprivation Parents remove effects if child addicted. Repeated computer/game from home cycles damage relationship Child’s attitude improves Period of child working to get computer back

Parents return computer to home

Options: 1. Give up 2. Remove computer long term 3. Seek professional tx

Child Abuses Computer Period of escalating anger, poor school performance, sleep Longer term Parent removes computer issues. Parents finally cycle have had enough! Sometimes this is encouraged by mental Parent demands child’s health professionals. performance improves as condition to return computer Period of parents and child locked Child demands computer in power struggle as condition for school improvement or attendance Options: OR shuts down, sleeps 1. Give up excessively in apparent 2. Seek (new) professional Tx “depression” 3. Send child away for Tx

(c)2019 Kenneth M. Woog, Psy. D. 35 Individual / Family Psychotherapy Challenges • Vast majority of clients were male, adolescents or young adults • Brought into treatment by parents • Very poor insight – often less mature than chronological age • > ADHD, ASD, introversion/socially anxious, avoidant • Clients did not want counseling or therapy • Minimization/lied about actual hours played • Distrusting of counseling, uncomfortable in process • Traditional CBT difficult • “Dysfunctional thoughts?” • “This is a waste of time, I don’t have a problem” • Frequent no shows, last minute cancellations • Poor client engagement in treatment • Result: Involving parents improved participation • Better reporting, allowed for family based behavioral contracting

Behavioral Therapy Strategy: Behavioral Contracting to Agreed Daily Limits • Get computer time daily after completing responsibilities • Harm reduction model • Extra time to meet other responsibilities • Reduced risk of abreaction and power struggle Challenges • No way to validate amount of time spent on computer • Parents often unaware of client’s actual use levels • Attempts to rely on Parental Controls for limit setting failed because: • OS and Software Parental control limitations • Limited parental control capabilities • Easy workarounds • Child most often more tech-savvy than parents • “Beat the Parents” – a new game to win!

• Locked on computer video connection – VGA and DVI Port Models • Worked independent of Computer and Operating System • Limited when and how long computer can be used • Manual daily enable feature – parents must enable daily • No computer until homework was done • Recorded amount of time used, by day: reports • Approximately 1000 were produced/sold • Direct to treatment clients and sold online – ages 10-25 y/o • Results were encouraging • Treatment effects found even for those not in psychotherapy

• Psychiatrist not seeing the issue as a behavioral addiction • Avoidant clients not liking idea of the behavioral therapy • Psychiatrist office recommending client terminate • Psychiatrist or their intern doing individual therapy • Treatment individual only with no behavioral or family component • Found needed network of safe psychiatrist to refer to

• Nationwide Harris Poll Online survey, Gentile et al. (2009) • Sample of 1178 youth 8-18 years of age • 11 Questions Similar to Criteria for Pathological Gambling: • Negative Consequences of Play • Avoiding important academic, occupational or social responsibilities • Problematic behaviors as a result of play • 8.5% of respondents met 6 or more criteria • Male : Female 4:1 • Problematic use correlated to 25+ hours/week of play • If this is addiction, what was happening?

Developed by the National Institute on Drug Abuse (NIDA) National Institutes of Health Bethesda, Maryland

(c)2019 Kenneth M. Woog, Psy. D. 42 Science of Addiction Informs Treatment • Addiction is a disease where the reward pathway is hijacked • Repeated application of a substance or rewarding behavior – sufficient reinforcement • Treatment involves NEW learning in reward pathway, not discontinuance • New learning (connections) mediate and supplant old information. “Extinction” – Abstinence itself does not cure addiction • Evidence: Naltrexone and Alcoholism • Learning Theory: Operant and Classical Conditioning and Extinction Remember Behavioral Psych 101?

Program to train humans how to use the principles of behavioral psychology to train a virtual rat!

Treating Video game Addiction: • Reduce the Rewards of Game Play …. and continue to Play Fighting Fire with Fire • Can’t alter the game play itself* but we can reduce rewards indirectly through the amount of game play. *was required in China, now they require play limits for certain games • Modest reductions dramatically reduces opportunity to gain certain rewards: • Participation points - more you play, greater loot, status • Reduction in available computer time = significant reduction in “pseudo-play”: Pre and post game socializing, Watching gaming on Twitch, YouTube Time on discussion boards and involved in discussion with other players or teammates

• Continued play with reduced rewards = new learning

(c)2019 Kenneth M. Woog, Psy. D. “Harm Reduction” Treatment Model (2007) Gaming not allowed until after Addict Completes Daily responsibilities are completed. Responsibilities Repeated daily cycles + real world rewards = Addict Uses Computer with Total gaming time reduced limits until time runs out Harm Reduction

Addict is frustrated or angry Addict learns to accept about limits. Has extra free feelings of frustration, time to pursue other activities. cravings, while accruing • Behavior Therapy: significant real-life rewards • Computer use contingent on meeting other daily responsibilities (i.e. homework) • Reduce gaming rewards through reduction of game play time • Taper down use limits to reduce chance of serious abreaction, depression, self-harm • PC Moderator helpful to enforce limits, reduce conflict: minimize “Beat the Parents” game • Apply as long as possible, limits removed and Addict reassessed

• Individual Psychotherapy / Family Counseling • Limited or no participation by younger clients

(c)2019 Kenneth M. Woog, Psy. D. 45 Random Clinical Observations • Significant numbers of clients already had failed in and/or outpatient treatment • Adults regularly playing less than 25 hours/week seldom presented addicted. • Individuals not allowed to play videogames during the week (only weekends) during childhood were not immune to addiction later. • Problematic use resumed after periods of forced abstinence - sometimes even worse! • Psychotherapy in the absence of behavioral intervention showed poorer outcomes. • Brief behavioral intervention did not show lasting treatment effects • Premature conclusion of “successful” treatment problematic • Consistent application of the behavioral intervention, even in the absence of psychotherapy resulted in a reduced motivation for play for some clients, and these effects seem to persist long term. • Why? What were the processes that resulted in these treatment effects?

Harm Reduction Clinical Observations

• Problematic use resumed after periods of forced abstinence - sometimes even worse! • Psychotherapy in the absence of behavioral intervention showed poorer outcomes. • Brief behavioral intervention did not show lasting treatment effects • Premature conclusion of “successful” treatment problematic

• Consistent application of the behavioral intervention, even in the absence of psychotherapy resulted in a reduced motivation for play for some clients, and these effects seem to persist long term. • Why? What were the processes that resulted in these treatment effects?

• Striatal Dopamine confirmed reward center involvement • Structural / behavioral differences found • Game Players of Difference Game Genres • Positive changes observed showing improved functioning in logic or puzzle games • Negative changes observed in action based role-playing games. Problem solving relying on repetitive visual cues (memory) • Gaming Addicts vs. Controls • Negative changes linked to deficits in impulse control, behavioral inhibition, attentional capabilities, and cognitive functioning • Differences in observed activation to presented cues

Video to follow discusses cocaine but applies equally to all addictive substances or behaviors

Video Gaming

Food

Academic/Occupational Sports, Exercise

Recall /Anticipate Pleasurable Event

• Good News • Brain changes are not permanent • Restoration begins upon abstinence • Both reward center dopamine receptor and grey and white matter improvements seen, unclear if complete restoration possible • Bad News • Restoration takes time • Reward center learning does not change… without new learning

• The Really Good News: Evidence of Behavioral Addictions Mounting and the idea of Behavioral Addictions Become Mainstream

Problematic Gaming Research 2010-2019 • CBT Models of Internet Addiction and Gaming Disorder Emerging

• CBT Treatment Methods Proposed Based on These Models

• Methods followed those of substance abuse treatment • Poor Outcome Study Quality • Small sample sizes, lack of experimental controls • Limited specificity of use: Internet Addiction vs. Gaming Addiction • High dropout rates

• Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period: • Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life). • Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.) • Tolerance—the need to spend increasing amounts of time engaged in Internet games. • Unsuccessful attempts to control the participation in Internet games. • Loss of interests in previous hobbies and entertainment as a result of, and with the exception of, Internet games. • Continued excessive use of Internet games despite knowledge of psychosocial problems. • Has deceived family members, therapists, or others regarding the amount of Internet gaming. • Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety). • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games.

• Disorders due to substance use + Disorders due to addictive behaviors • Moved Gambling Disorder • Added Gaming Disorder • “gambling” changed to “gaming” • Online vs. offline dropped • Once and for all! • Severity not defined • Not Implemented until 1/1/2022

Gaming disorder is characterized by a pattern of persistent or recurrent gaming behaviour (‘digital gaming’ or ‘video-gaming’), which may be online (i.e., over the internet) or offline, manifested by: 1. impaired control over gaming (e.g., onset, frequency, intensity, duration, termination, context); 2. increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3. continuation or escalation of gaming despite the occurrence of negative consequences. The behaviour pattern is of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. The pattern of gaming behaviour may be continuous or episodic and recurrent. The gaming behaviour and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned, although the required duration may be shortened if all diagnostic requirements are met and symptoms are severe.

• Outpatient Individual Psychotherapy • Few specialists • Little guidance on treatment • Almost exclusively CBT • Medication – SSRIs, Anxiolytics • Treats symptoms and/or co-occurring mental illness

“Real World” Treatment Methods: 2019

• Wilderness Programs / Camps / Retreats / Wellness Centers • Limited specialized treatment

• Inpatient/Residential Rehabs • Rapidly Emerging Field • Teens – Deviant peer influences • Adult – Substance Addiction Treatment Centers (Google it!) • Few Experienced Programs • reStart • Luxury gaming addiction rehabs

Gaming Disorder 2019 • Gaming Disorder a growing health concern worldwide • Number of individuals playing videogames increasing • Rapid Growth in the Videogame Industry • Desktop, Console and Mobile gaming • Research in practical, effective treatment methods still lacking • Lack of standardized measures, small size, lack of follow up, self-report • Often no distinction between Internet Addiction and Gaming Addiction • CBT treatment methods studied (group and individual) • College student subjects • Only one small scale randomized clinical trial • Few family based treatment studies reported • No behavioral treatment methods studied • Small medication studies not compared with placebo • Bupropion, methylphenidate and others

Gaming Disorder 2019 (continued) • Few treatment methods targeting parent-referred clients • Populations very likely to appear in outpatient settings • Male teens (13-17) defiant behavior, school failure/online school • Young male adults living with parents – college failure, failure to launch, pro gamer aspirations • Developmentally delayed, co-occurring mental illness • Studies of Prevention Programs Limited • School based programs mostly from Asia (South Korea, China)

• ICD-11 Gaming Disorder soon a diagnosable condition • Insurance reimbursement • With no standard of care, what will be reimbursed?

My Treatment Methods: 2019 • Intake: Assessment, Psychoeducation, Treatment Planning/Goal Setting • Client chooses treatment goals: abstinence (rare) or moderation • Weekly Individual Psychotherapy / Coaching with Parent/Family Participation • Include parents in treatment (co-therapist) from the beginning • Acceptance and Commitment Therapy (ACT) positioned as “skills building” • Refer out for medication or adjunct individual psychotherapy • Behavior Therapy: • Use of technology contingent on meeting important responsibilities • “Game play time is zero when it needs to be zero” • Parents play important role in enforcing / monitoring behavioral program • Treatment effects tested by fading/removing limits and observing outcome • PC Moderator obsolete, Sentinel Gaming System Developed

Models for Addiction and Dependency would: • Inform Treatment • Explain observed treatment results using behavioral methods • Develop specialized treatment methods • Help Educate Patients and Families in Treatment • Better understanding increases participation • Inform Prevention • Identify risk factors • Inform preventions measures • Establish informed parenting recommendations

NIDA Dependence Definition: Withdrawal “Presence of a drug” but withdrawal symptoms observed in clinical practice for gaming addiction Psychological Dependence (new): A state in which an organism functions normally only when able to regularly engage in a specific behavior. Manifested as an emotional disturbance when the ability to engage in the behavior is restricted.

NIDA Addiction Definition Behavioral Definition: Covers both substance and behavioral addictions.

(c)2019 Kenneth M. Woog, Psy. D. 64 Observed Effects of Video Game Addiction • Neural connections (wiring) established to record the associations between the reinforcing behavior and pleasure • These pathways are learned through behavioral conditioning • Cannot be unlearned - New learning is required to mediate this wiring • Receptor atrophy occurs in the dopamine receptors within the reward pathways • General reduction in motivation, interest in other activities • Receptors restore over time if excitation levels moderated • Grey and white matter abnormalities identified • Judgment, impulse control deficits assumed related to these brain areas • Evidence suggests these changes can reverse if gaming time reduced • Co-occurring mood disorders, compromised coping strategies • Negative life outcomes • Family conflict, academic/occupational/ social/health issues

A state in which an organism functions normally only when able to regularly engage in a specific behavior. Manifested as an emotional disturbance when the ability to engage in the behavior is restricted.

DSM-5 Internet Gaming Disorder Dependency Symptoms Direct Symptoms • Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.) • Use of Internet games to escape or relieve a negative mood (e.g., feelings of helplessness, guilt, anxiety).

Source of Emotional Disturbance • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of participation in Internet games. • Continued excessive use of Internet games despite knowledge of psychosocial problems.

Recent Research Captured the Essence of Dependency Depressive Symptoms and Problematic Internet Use Among Adolescents: Analysis of the Longitudinal Relationships from the Cognitive–Behavioral Model Manuel Gamez-Guadix, PhD (2014)

• Negative outcomes at an academic, family or social level due to problematic internet use predicted increase in depression symptoms 1 year later • Depressive symptoms at time 1 predicted problematic internet use with negative outcomes one year later (c)2019 Kenneth M. Woog, Psy. D. 67 Simplified Gaming* Dependence Model

Negative Mood States 1 (Anxiety, Depression, Boredom)

2 Excess Gaming*

* Substitute “Media Consumption” Negative Real-life for word “Gaming” to make suitable for client presentation Outcomes and to encompass alternate behaviors such as watching YouTube or Twitch

Excess Consistent daily usage 2 Gaming limits to “safe” levels

Enrichment activities Negative Real- (work, school, social), life Outcomes Family Involvement, Career/Academic Assessment

• No single number - varies individual to individual • Genetic/individual variability, life circumstances • Impairment above 15 hours/week • Time includes all related activities – Twitch, YouTube, Discord • Significant impairment found at 25 hours/week • Safe does not mean appropriate for lifestyle / commitments • College, high school students, athletes, parent, spouse • Never binge for more than 5 hours in any one day!

Little Impairment Mild Impairment Modest Impairment Serious Impairment

Not dependent Likely dependent Dependent

5 15 25 35 45 55 65 hrs/week

Establish a Relationship Negative Mood States (Anxiety, Depression, Between Work and Play Boredom, Cravings) Limiting gaming and Emotional Regulation Skills replacing time with Exposure to negative mood responsibilities and states with restricted gaming enrichment activities Restricted Access to Gaming motivates acquisition of psychological flexibility skills

Contingency established Responsibilities and Reversal of Negative Life Responsibilities and Enrichment Activities Outcomes Enrichment Activities (+) are contingency for Gaming Life Rewards Accrue Time (-). (Premack Principle) Positive outcomes and rewards from Limited Gaming Time meeting responsibilities and “Safe Levels” enrichment activities reverse negative life outcomes

Reduction in Negative Mood Improvement Mood States

A state in which an organism engages in a compulsive behavior • The behavior is reinforcing (rewarding or pleasurable) • Loss of control in limiting intake

DSM-5 Internet Gaming Disorder Addiction Symptoms Symptoms • Continued excessive use of Internet games despite knowledge of psychosocial problems. • Tolerance—the need to spend increasing amounts of time engaged in Internet games. • Unsuccessful attempts to control the participation in Internet games.

Initiate Game Play Play

After sufficient play, reward pathway is hijacked and Reward Pathway structural brain changes Conditioning & lead to reduced coping and Structural Changes self regulation functioning

Cue-reactive craving Cues with reduced behavioral inhibition

Decrease consumption levels, Initiate Game Play Increase competing activities: Play Sports, academics, off-line socializing, family involvement

Decrease game rewards directly via reduced play outcomes (loot, ranking, Reward Pathway team ranking), punish play through Conditioning & less desired contingencies, interrupted Structural Changes play and team displacement. Reduced play time over extended period to restore structural deficits

Limit access (strongly enforced) to Cue-reactive craving play/pseudo-play (ERP), Mindfulness Cues with reduced based cognitive psychotherapy. behavioral inhibition Medications an option to reduce craving, mood disturbance and impulsivity

Gaming not allowed until after Addict Completes Daily responsibilities are completed. Responsibilities Repeated daily Premack Principle cycles + real world rewards Addict Uses Computer with Total gaming time reduced limits until time runs out Gaming Rewards Reduced Conditioning

Addict is frustrated or angry Addict exposed to cravings about limits. Has extra free and prevented from time to pursue other activities. gaming. When time runs out, gaming is interrupted Time freed from excess thus exposing addict to Sometimes responsibilities computer use applied to difficult emotions. limit access to gaming on any enrichment activities Exposure and Response given day. “Zero when it resulting in real-life rewards Prevention needs to be zero”. and reversal of negative life Intermittent Reinforcement outcomes. Reinforcement of newly conditioned behaviors

To increase the frequency of a less preferred activity, Less Preferred Activity a more preferred activity is (Homework) + made contingent upon the occurrence of the less preferred activity. More Preferred Activity But less known relationship: (Videogame Play) - This contingency will also decrease the frequency of the more preferred activity. Contingency Established

Videogame play causes Homework behavior to increase BUT as importantly in this case Videogame Play is reduced

Premack Principle Game Play restricted (ERP): Contingency established Responsibilities and 1. Until allowed time between responsibilities and Enrichment Activities 2. Without contingency gaming results in an increase in 3. Upon intermittent motivation for performing reinforcement schedule responsibilities Restricted Access to Gaming BUT MORE IMPORTANT motivation for Game Play is reduced Game Play Changes to Reward Pathway (at Reduced Levels) Structural Change Reversal Play at reduced levels over an extended timeframe results in End of play time Interruption Interruption of Play reduction in motivation to play Punishes Game Play and reversal of structural deficits Cue-reactive craving with Cues reduced behavioral inhibition

Being present: Not tuning out the world to escape my pain and life circumstances

What is important for Willingness to have difficult my future? Career, internal experiences if it’s relationships, hobbies, important interests?

Goal setting, Awareness of my thoughts: organizing life, doing are they helpful or giving what you commit to me short term relief?

Gaining self- awareness. Don’t believe the stories

79 (c)2019 Kenneth M. Woog, Psy. D. Individual-Focused ACT Treatment with Parental Participation How it works • Suitable for clients aged 13 (depending on maturity) to 35 • Parent(s) attends initial assessment and most sessions • ACT Model explained as tool to deal with “media dependency” • Initial sessions focus on skills building, later on outcome monitoring • Parents assume co-therapist role and manage behavioral program • Parents ensure client participation in between session assignments Benefits • Improved client attendance and participation • Engenders hope and involvement for parents, improving willingness to continue in treatment • ACT work with parents reduces codependency • Regular weekly treatment outcome assessment Risks • Parental burnout, schedule conflicts • Parental psychopathology, excess family conflict

• Adjunctive treatment based on the client or parent’s needs • Evaluation for these issues ongoing throughout treatment • May be recommended for client and/or parent • Individual Psychotherapy, Parent Counseling • Conditions affecting client’s ability to benefit from behavioral treatment • MDD, ADHD, GAD, OCD, PTSD, CD, BD, Schizophrenia • Adjustment, grief/loss, substance issues, chronic illness, codependency, marital conflict, • Other specialized behaviors addictions or compulsive behaviors such as: • Sexual addiction, deviant sexual behaviors • Gambling addiction • Eating disorders

(c)2019 Kenneth M. Woog, Psy. D. 81 Medical/Medication Treatment (as needed) • Adjunctive treatment based on the client individual psychopathology and/or health needs • Evaluation for these issues ongoing throughout treatment • Conditions affecting client’s ability to benefit from behavioral treatment • MDD, ADHD, GAD, OCD, PTSD, Bipolar, Schizophrenia, ASD • Antidepressants medications (often with anti-anxiety component) • Stimulant medication (for ADHD) • Mood stabilizers (for Bipolar Disorder) • Anti-psychotics (for aggression, psychotic symptoms) • NEVER benzodiazepine or medical marijuana • Temporary hospitalizations, inpatient treatment • Suicidal thoughts, actions, decompensation • Extreme defiance with physical and property violence • Co-occurring substance dependency

Integrative Multi-Modal Treatment Model

= Behavioral interventions create contingencies, and enforce limits on reduced levels of use + • Cognitive Behavioral interventions target coping with difficult internal experiences • Craving/urges, unhelpful thoughts, beliefs, symptoms of depression/anxiety • Identify alternate rewarding activities to replace gaming time • Family format to enhance participation, behavioral involvement and enhance family relations • Family counseling as appropriate • Parents enlisted to enforce behavioral interventions in the home • Adjunctive Individual psychotherapy for co-occurring disorders or issues interfering with treatment • Medical, medication interventions may be necessary to treat psychiatric disorders, improve coping

(c)2019 Kenneth M. Woog, Psy. D. 83 Interventions and Intended Outcomes Interventions/ Lifestyle Changes Intended Outcome Physical activity, diet, sleep, hygiene, Negative Mood States (Anxiety, Depression, Enhanced Coping Response other leisure activities, psychotherapy, to Negative Mood States family counseling, medication Boredom, Cravings)

Counseling / coaching - identify enrichment activities (occupational, Engage in Responsibilities Reversal of Negative Life education, social, spiritual, recreational and Enrichment Activities Outcomes, Mood Elevation etc.), establish daily schedule

Restrict access to gaming until end of day, contingent on other responsibilities and for Restricted Access Reward Sensitivity Restored reduced amount of time, tapering down as to Gaming Structural Deficits Reversed needed for safety and efficacy

Game play daily with reduced rewards Game Play with Reduced New Reward Pathway Learning as a consequence of reduced play. No Game Rewards Reducing Motivation for Play play when it needs to be zero

Scheduled wind down after play ends Interrupt Play and Improvement in Emotional psychoeducation, psychotherapy to Restrict Play Until Next Day Regulation / Coping Skills deal with urges and impulses.

Cue-reactive Craving With Restricted Access External Cues Reduced Behavioral Inhibition to Gaming 84 (c)2019 Kenneth M. Woog, Psy. D. Intake Assessment (2 hours) • Obtain consent for treatment • Answer questions, discuss issues, concerns • Establish rapport with all family members • Assess for behavioral addiction, dependency • Identify level of impairment, negative life outcomes, strengths • Identify client’s goals for treatment • Discuss with client and parents for consensus • Establish initial behavioral change goals • Psychoeducation on addiction, dependency and therapy process • Science of Addiction, Dependency Model • Attempt to get acknowledgement of client’s dependency • Gain agreement from all to participate in treatment • Client assignment – read The Happiness Trap, Mindfulness Video

• Assess the problem – questionnaires, interviews • Include parents/significant others if possible/necessary • Identify the negative impact on health, academic, occupational and social domains (Motivational Interviewing) • Identify the impact on the family/couple • Assess for related mental health issues • Depression, anxiety, system, developmental delays, other • Identify the amount and times of play AND pseudo-play

Little Impairment from gaming Serious Impairment

Not addicted Likely Addicted Addicted

5 15 25 35 45 55 65 hrs/week

• Provide a tentative, limited diagnosis • Brief psycho-education critical • Science of Addiction, game culture, treatment methods • “Never pull plug on game play” • Discuss goals for treatment • Ask both parents/spouse and addict separately: • “What do you think is a reasonable amount of time?” • “What important responsibilities have suffered as a result of gaming?” • Abstinence or moderation? • Negotiate to starting point - how much and when each day • Discuss reasonable expectations for parents/significant others • Develop the treatment plan • Educate client and family, seek buy-in from client • Contract for specific number of sessions

Experiences difficult internal experiences: cravings, stress, unpleasant thoughts and feelings, physical pain, hunger.

Plays videogames (dissociative experience) and awareness of difficult experiences ends. Senses personal worth, value and belonging. Significant mood elevation. Play until exhausted, pushing past sleepiness. Go to sleep.

Real-life problems mount. Ignore, Repeat

Younger Clients: I don’t need to see a therapist. I don’t have a problem. You see a therapist! Older Clients: Ok I will go to see the counselor if you stop bugging me! … no-shows, cancellations, excuses, between session assignments ignored (c)2019 Kenneth M. Woog, Psy. D. 88 Enhance Motivation for Treatment • Psychoeducation on Dependency Model • First session important to build rapport • Value/meaning of gaming to client • Know the games, know the client • Implications for treatment? • Motivational interviewing (difficult) • Psychoeducation on psychotherapy • ACT positioned as skills building for all • Call for reduction in game play to “safe levels” • Identify client readiness, willingness • Engage both client and parents • Improved attendance, participation and between session assignment compliance • Necessary before moving to behavioral contracting and treatment methods • May take several sessions and values based activities

(c)2019 Kenneth M. Woog, Psy. D. 89 Behavioral Treatment Preparation • Review of between session assignment • Overview of ACT • Relevant examples and metaphors • Presented as skills and tools to learn • Overview of importance of healthy lifestyle: • Adequate sleep and sleep schedule, diet, exercise other leisure activities, socializing • Discuss importance of regular weekly schedule • Introduce behavior plan implementation methods • Limits? Client usually claim “I can do it on my own” – if addicted, not likely • Client assignment: Create Weekly Schedule • Tools available on Google Sheets • Share with therapist and parents

(c)2019 Kenneth M. Woog, Psy. D. 90 Initiate Behavior Plan • Discuss client’s prepared weekly schedule • Confirm activities appropriately scheduled • Ensure media time is at end of day and contingent on completing important responsibilities, chores, enrichment activities • Discuss behavior plan implementation • Who is monitoring, limiting or enabling daily media use • Challenges, issues • Practical application of ACT principles to this process • Procrastination, parenting difficulties • Values work – career assessment, academic assessment, etc.

(c)2019 Kenneth M. Woog, Psy. D. 91 Ongoing Weekly Counseling Sessions • Review behavior plan: • Results, client compliance • Review client’s weekly schedule • Help parents maintain behavioral treatment integrity • Individual, Parent and Family Issues • Assess for depression, suicidality • Conflict, communications issues • Parent assessment – how are they doing • Assess need for referral for individual therapy and/or medical • ACT psychotherapy (family) as skills building, coaching process • Career assessment, advisement, life coaching as needed • Assess need for ongoing sessions, taper as needed

• Too Many Devices To Track!! • Some you may not know they have • 24/7 Content Access • Many Ways to Connect • Cell Data, WIFI • Downloadable content • Device Controls Not That Secure • Many Ways to Bypass – Google it! • More “Beat the Parents Game”! • Its fun and they often win! • Internet/Gaming Cafes, Coffee Shops With WIFI Hotspots

(c)2019 Kenneth M. Woog, Psy. D. 93 Simplify Media/Gaming Device Availability • Consolidate client’s gaming/media use to one device • Other user’s computers/tablets/smartphones in home must be secured (password protected, locked away) • Client’s other computers must be removed • These allows secretive use and use in bed, bathroom, etc. • Addict’s other media devices except smartphone must be removed • No more Tablets, Ipods (except Nano) • Additional gaming consoles or handheld system must be removed • If possible move computer system into a common area • Install/configure limit setting tool (parental control) on System • Agreement that use would not start until certain time • Set to agreed upon daily limits • If user cannot self-limit, then they meet the definition of addict • For adults: allow attempt to self regulate smartphone first • If unsuccessful then they must give up the device • Sentinel Gaming System developed for difficult cases

(c)2019 Kenneth M. Woog, Psy. D. 94 Limit Setting Tools • Parental Controls for the System, Game or App • Limits application time (i.e. World of Warcraft) • PlayStation, XBOX and other consoles • Limited to application (pseudo play?) • Router Control Applications • Simple: Power off router at night, Disney Circle • Parental Control Software with Time Limit Features • Parents must be System Administrator, potential for hacking • Windows 10 and Mac OS allow when and daily limit settings • Parents/Significant Others are System Administrators • Self-Limiting Software Tools/Apps provide feedback • Rescue Time, Stop Procrastinating • Keep vigilant! There are workarounds or ways to fool parents

(c)2019 Kenneth M. Woog, Psy. D. 95 Sentinel Gaming Systems™ The First Desktop Gaming Computer Designed for the Prevention and Treatment of Videogame Addiction • High Performance Gaming Desktop PC • Windows 10 OS, VR, 4K ready • Plays PC, XBOX One*, PS4* Games & Your Phone (Android) • Designed for behavioral treatment protocol • Automate behavioral contingencies, *Running a Windows 10 app and you • Gradual tapering down use automatically must have the console and games • Web based controls can be operated from anywhere with internet • View current status or modify settings/limits in real time • Usage monitored (when, how long and even view screen images) • Settings for when, how long and how users can operate system • Gaming Mode, Study Mode, No Video Modes, GamePlay+ • Users may remain System Administrator of the computer system • Highly Secure – Tamper and hack resistant • Began field testing in 2015 with videogame addicted clients • Very encouraging results, supported the behavioral treatment protocol • Presented to clients as last resort, the threat alone has motivate some clients! • More info: sentinelgamingsystems.com (c)2019 Kenneth M. Woog, Psy. D. 96

Solutions to Limit Setting Difficulties • The Threat of the Sentinel Gaming System Can Be a Motivator • Tell them this a last resort option • It can play their games: PC, XBOX*, PlayStation* and Android* *Running a Windows 10 app and you must have the console and games • It has changed behavior of children and adults just knowing it exists! Soon available to general public

• If Client Unable to Self Regulate: Install the Sentinel Gaming System • Says “Game Over” to the “Beat the Parents” Game • Designed specifically in support of the behavioral treatment program • Study Mode allows computer use but not gaming or watching videos • Daily Gaming Enable makes contingency setting easy • Taper down use automatically • Remotely monitor use (screen images)

Smartest Phone for Smartphone Issues and Dependency

• Clients will switch to gaming on smartphones at night as a way to avoid limits • Cellphone Carriers have parental controls to allow a limited set of control options • But if client unable to self-regulate smartphone use: gaming, watching videos or social media • Parents should replace it with “Dumbphone” • Important: Do not allow client to retain the smartphone or they can use it with WIFI! • Yes they are still available • Client will give tremendous push back on this • Parent will often cave • This can be a big barrier to success treatment

• Bottom Line: If you can’t manage it, get rid of it!

• Clients will switch to gaming on smartphones at night as a way to avoid limits • Cellphone Carriers have parental controls to allow a limited set of control option • But if client unable to self-regulate smartphone use: gaming, watching videos or social media • Parents should replace it with “Dumbphone” • Important: Do not allow client to retain the smartphone or they can use it with WIFI! • Yes they are still available • Client will give tremendous push back on this • Parent will often cave • This can be a big barrier to success treatment

• Bottom Line: If you can’t manage it, get rid of it!

Case Studies Representing the Treatment Model Presented

Sampling of Clients of Dr. Kenneth Woog 2005 - 2019 Some details modified to ensure confidentiality

• 17 y/o male WOW Addiction • Declining / failing grades in high school • Therapist recommended parents remove computer from home until client attended school reliably for two weeks and brought grades up • Parent: “2 weeks of attending school and doing h/w, get computer back” • Child: “Give me back computer or I won’t go to school • 30 days later… still not in school • Setup PC Moderator with computer time allowed for attending school, even part day • 1 hour school= 1/2 hour computer time • Back in school full time within 1 week • Limits set to daily (2 hours) and weekend (5 hours) use and contingent on doing h/w each weekday

(c)2019Kenneth M. Woog, Psy. D. 100 Case Study – 20 years old • WOW addiction, academic suspension, at home, not working • Treatment resistant, poor relationship with parents, no close friends. • Attempted weekly family counseling with ACT, behavior contracting - poor participation, poor outcome. Referred out for psychiatric medication evaluation. Dx of cyclothymic disorder confirmed, placed on medication. • Established behavior program with PC Moderator, Client returned to college commuting from home. Had very successful summer college term, conflict with parents subsided. • Parents insist on client returning to college Fall term against my recommendations • Client returns to dorms with computer and PC Moderator. Therapy stops, client not medication compliant. Removes PC Moderator, stops attending classes, failing out of school again. • Client sees a different psychiatrist and never returned for treatment, chose to terminate and do individual therapy work with new psychiatrist

(c)2019 Kenneth M. Woog, Psy. D. 101 Case Study – 25 years old • Had been attending local university for a long time, completed all the credits to graduate but his GPA was below 2.0. Had retaken so many classes could only take 400 level courses to bring up GPA. Parents brought him for treatment for videogame addiction. • Had started new school term with 2 classes, parents worried this would be his last and not graduate. Client claimed he could regulate on his own. • Had done a few family sessions, then parents not willing to participate and continued with individual sessions. Was open, honest and participated in therapy. Recommended Sentinel early on but was refused by client and parents. • Despite client’s self report of good school performance, at midterm, client had an F and a D+ in his courses. • All agreed to Sentinel and behavior plan of studying 8 hours/day and getting 3 hours of gaming time. Parents could not support the behavioral plan, so I did it myself. • Client ended term with an A and B in his classes.

(c)2019 Kenneth M. Woog, Psy. D. 102 Case Study – 30 years old • Referred by primary therapist that had been seeing him off and on since high school regarding video gaming excesses. Despite excess gaming and resulting serious issues such as repeated school failure, client was able to eventually graduate college, law school and pass the Bar exam. • For two years after passing the bar exam he was living at home, gaming > 60hrs/week, unemployed and not looking for work. He had few friends and was not socializing. • Employed ACT based family-based individual focused sessions, established a behavioral program with gaming as a contingency of completing job seeking activities and doing pro- bono work. Client began to seek employment and was hired as a law clerk within 3 months. It was understood that he would continue looking for work as an attorney. He did not. • Sentinel was used, however client began using his smartphone for media consumption. His therapist and I recommended giving up the smartphone, client refused and parents refused to enforce an ultimatum. Agreements for living in the home were made and broken. • Client claims to have lost complete interest in gaming, has a girlfriend, continues to work as a law clerk and, despite the fear of being kicked out of his parent’s home still will not look for a new job. • Gaming no longer motivated client, so client given option to move out or look for work approximately 20 hours/week, using the Sentinel for accountability. Has begun job seeking.

Age Referral Reason Behavior Tx Ind. Tx Family Tx Current Status 25 College suspension Sentinel yes as needed ongoing, successful college term 22 College suspension self no no failed recent college term 22 College suspension Sentinel yes 1/month ongoing, successful college term 31 No school, no work Sentinel no 1/week successful college term, employed, moved out 20 College suspension self no as needed failed college, returning to cc college 27 Unemployed, gaming self yes as needed employed, gaming 5-10 hrs./week 16 Declining academics self no 3 sessions schoolwork improved, refused Sentinel 23 College suspension abstinence ended 10 sessions working full time, not gaming, returning to College 23 College suspension Sentinel no 1/week working, successful college term, stopped gaming 27 Unemployed, gaming self no 1/month paid part time employment, gaming >35 hrs./week 23 Failing college Sentinel yes 1/week successful college term 20 College suspension Sentinel yes as needed successful college term 20 Gaming all waking hrs. self outside 1/week no improvements, parents just agreed to Sentinel 20 College suspension self no 1/week started working, gaming to excess, Sentinel on order

(c)2019 Kenneth M. Woog, Psy. D. 104 Final Notes • Strict behavioral plan combined with family ACT work and parental participation appears to offer the best outcome • Can result in dramatic reduction in motivation for play • Sentinel use shows much better results than attempts at self-regulation • Even for some complete loss of interest in gaming • Future studies using the Sentinel are being planned • Sentinel recommendation: conflict of interest? • If I wait to make recommendations, risk of treatment failure, premature termination of treatment • If I recommend too soon, perception that I am pushing Sentinels and client pushback • Must present as a last resort if client can self regulate • Smartphones can be obstacles for treatment • Must be removed if becoming a substitute for PC or console gaming • Treatment process takes time and the effects must be tested prior to termination

Gaming Disorder Prevention and Treatment Treating Fire with Fire

Prevention and Early Intervention

Debra Woog, MPC, MA LMFT Computer Addiction Treatment Program

Primary, Secondary, Tertiary Prevention/Intervention-

• Primary Prevention/Intervention-preventing a problem so that it does not occur. Preventing exposure to hazards that can lead to problem. • Secondary prevention/intervention-assessing and treating a problem as soon as possible to halt or slow its progression. • Tertiary prevention/intervention- Helping people treat and manage the problem in order to restore quality of life once problem is present.

Elementary School Education -Educating parents and educators on importance of contingency usage and limits on gaming.

-Education about importance of enrichment activities and socialization not derived from games.

Secondary,Tertiary Prevention/Intervention

At-risk Youth Identification Grades 5-6, middle school, high school, college -assessing and treating

Educators, school counselors must screen and offer resources, not accommodation when gaming is interfering with school success. (Not continuation, on-line or home school solutions) -Educate them about the problem and treatment resources available

Health professionals must screen for this problem Primary care physicians, school nurses, psychiatrists, psychologists, MFT/counselors -Offer materials/information on problem and treatment resources

• Create strict use contingencies and enforce “safe” daily limits on media consumption • Monitor a child’s media and gaming activity to ensure safety and appropriateness • Ensure child gets adequate sleep and physical activity, healthy diet, enjoys other leisure activities and participates in a variety of enrichment activities. • Ensure child’s needs for achievement, success is met through academics, sports, artistic expression, etc. • Ensure child’s needs for connection with others is met through face-to-face contact. • Ensure child’s emotional development is promoted with support, encouragement and empathy from parents and other loved ones. • Not primarily from online gaming friends • Expect this to be an ongoing battle – no one said this was easy • Videogame industry and new societal norms putting pressure on parents • Test your child’s ability to self regulate before they go off to college • Relax limits with understanding this is a test of self-regulation and readiness for college

(c)2019 Debra S.Woog, MA, LMFT 110 So How Much Gaming Time is Safe? Safe and Appropriate are Not the Same • Pre-school age children Screen time recommendations 0-1 y/o 2-4 y/o 5-18 y/o • Parents and technology 0 <1 N/A • Many parents use technology 0-2 2-5 y/o 6-18 y/o as a parent helper. 0 <1 “Balance”

• Elementary, Middle School, High School • No guidance from WHO or AAP on amount of time • Lifestyle balance, AAP has Media Time Calculator (Hint: just leftover time) • Guidance on limits to video gaming + other technology screen time* Gentile et al. (2009), 25+ hrs./week significantly problematic 8 -18 y/o • 6-7 (Elementary) <1 hr./day, maximum 6 hrs./week • 8-11 (Elementary) <1.5 hrs./day, maximum 9 hrs./week • 12-13 (Middle School) <2 hrs./day, maximum 12 hrs. /week • 14-18 (High School) < 2.5 hrs./day 15 hrs. /week

*These recommendations from Kenneth. Woog, Psy.D. are starting points for safe limits. Reduce times if problems emerge or if incompatible with child’s and/or parent’s lifestyle.

(c)2019 Kenneth M. Woog, Psy. D. 111 What Parents Need to Know: College Kids • If your college bound child has had issues with gaming before college, this will not go away when they reach college • Stress, isolation, loneliness, boredom • Lots of videogame play in college dorms! • Demand 100% access to your child’s school on-line accounts. • Not just the guest account • Request access to their course syllabus • Ask them about their study habits • Regularly check your child’s account to verify class participation and grades. • Know their classes and schedule • Academic suspension is too late • Check in with your child regularly from day one • Empathize with struggles • Increased avoidance of parental contact is a common red flag • Visit your child at school unannounced, even if things appear to be going well • Seek professional help at the first sign of problems (c)2019 Debra S.Woog, MA, LMFT 112 Final Words

“With technology we are bringing boredom to the brink of extinction. Satisfying this with the immediate gratification of media consumption may have tragic consequences for mankind”

• Cash, H. (2012). Internet Addiction: A Brief Summary of Research and Practice. Current Psychiatry Reviews. Vol .8, No. 4. • Casino.org (2019) Most Addictive Video Games 2019 https://www.casino.org/most-addictive-video-games • DSM-5 (2013) American Psychiatric Association • DFC Intelligence (2019) Worldwide Video Game Market Forecasts • Dong, G. et al (2014) A cognitive-behavioral model of Internet gaming disorder: Theoretical underpinnings and clinical implications. Journal of Psychiatric Research. Nov;58: 7–11. • Gamez-Guadix, M. (2014) Depressive Symptoms and Problematic Internet Use Among Adolescents: Analysis of the Longitudinal Relationships from the Cognitive–Behavioral Model. Cyberpsychol ology Behavior and Social Networking Nov;17(11):714-9. doi: 10.1089/cyber.2014.0226. • Griffiths, M. (2012) Video Game Addiction: Past, Present and Future. Current Psychiatry Reviews. Vol 8, No. 4.

• Harris, R. (2009). ACT Made Simple: An Easy-To-Read Primer on Acceptance and Commitment Therapy. Oakland, CA: New Harbinger • King, Daniel & Delfabbro, Paul. (2018). Internet Gaming Disorder: Theory, Assessment, Prevention, and Treatment (1st Edition). 10.1016/C2016-0- 04107-4. • NBC News.com Rock Center (2012) Tangled Web. retrieved from: http://www.nbcnews.com/video/rock-center/49754151#49754151 • NIDA (2007) The Science of Addiction. Retrieved from: http://www.nida.nih.gov/scienceofaddiction/ • Palaus, Marc et al. (2017) Neural Basis of Video Gaming: A Systematic Review. Frontiers in Human Neuroscience Vol 11 • PC Moderator (2006) PC Magazine Review. Retrieved from http://www.pcmag.com/article2/0,2817,1948177,00.asp

(c)2019 Kenneth M. Woog, Psy. D. 118 Credits / References / Resources • Southpark - Comedy Central, Season 10, “Make Love, Not Warcraft” • Wölfling, Klaus, et al. (2019). Efficacy of Short-term Treatment of Internet and Computer Game Addiction. A Randomized Clinical Trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.1676. • World Health Organization (2018), Gaming Disorder http://www.who.int/features/qa/gaming-disorder/en/ • Woog, K. (2006) How tech savvy teens defeat parental controls http://www.pcmoderator.com/wooglabs3_018.htm • Woog, K. (2004) A survey of mental health professionals clinical exposure to problematic computer use. http://www.pcmoderator.com/research.pdf • Woog, K. (2016). Proposed gaming addiction behavioral treatment method. Addicta: The Turkish Journal on Addictions, 3, 271–279. • Yee, N. (2002) Ariadne - Understanding MMORPG Addiction, retrieved from http://www.nickyee.com/hub/addiction/home.html • Young, Kimberly et al. (2010) Internet Addiction: A Handbook and Guide to Evaluation and Treatment. Hoboken NJ: John Wiley & Sons

David Greenfield, Ph.D. - The Center for Internet and Technology Addiction West Hartford, CT 06119 860-561-8727

Hillarie Cash, Ph.D. - Internet/Computer Addiction Services Redmond, WA. 98052, (425) 861-5504

Kenneth Woog, Psy.D. - Computer Addiction Treatment Program Lake Forest, Ca 92630, (949) 422-4120

Kimberly Young, Ph.D. - Center for Internet Addiction Recovery Bradford, PA 16701 814-451-2405

Link to presentation in .pdf format http://www.computergamingaddiction.com/firewithfire.pdf

Questions?

Presentation: computergamingaddiction.com/treatingfirewithfire.pdf